Reclamaciones médico-legales y cirugía de varices. Peritajes de un cirujano vascular durante 25 años / Medicolegal claims and varicose vein surgery. Expert reports presented by vascular surgeon over a 25 year period, and literature review

INTRODUCCIÓN: En nuestro país no son bien conocidas las causas que originan reclamaciones judiciales en cirugía vascular. OBJETIVO: Determinar situaciones de riesgo que inducen reclamaciones en cirugía de las varices y proponer recomendaciones para su prevención. MATERIAL Y MÉTODOS: Estudio retrospectivo de la documentación de un cirujano vascular sobre los peritajes por él realizados ante reclamaciones judiciales en angiología y cirugía vascular durante 25 años (1990-2015). Conjuntamente, se efectúa una revisión-análisis de la literatura. RESULTADOS: Se encontró un total de 10 peritajes médico-legales por reclamaciones derivadas de enfermedad vascular, lo que supone 0,40 casos/año (1 cada 3 años). Ocho fueron por enfermedad venosa (80%) y 2 por enfermedad arterial (20%). Del total, 8 fueron complicaciones durante o después de la cirugía (80%), 3 de ellas con resultado de muerte (37,5%). La cirugía de las varices motivó 6 demandas: 2 lesiones nerviosas (nervio ciático y nervio safeno), una por stripping de la arteria femoral superficial y 3 por embolia pulmonar mortal. Según nuestra documentación, ningún dictamen judicial condenó al médico. Un demandante recibió indemnización económica. Otro dictamen condenó a la demandante a pagar las costas del juicio. Esta pequeña serie coincide, en gran parte, con las causas de reclamación señaladas en la literatura. CONCLUSIÓN: Comparada con otras especialidades, la cirugía vascular no presenta un alto volumen de reclamaciones. No obstante, dentro de la cirugía vascular, el tratamiento de las varices supone una parcela de alto riesgo. De forma específica, la prevención de la embolia pulmonar es un aspecto de primer orden para evitar reclamaciones médico-legales

INTRODUCTION: The causes of legal claims in vascular surgery are not very well-known in Spain. OBJECTIVE: To identify risk situations that lead to claims in surgery of varicose veins and propose recommendations for prevention. MATERIALS AND METHODS: Retrospective study documenting the expert reports presented by a vascular surgeon on legal claims in angiology and vascular surgery over a 25 year period (1990-2015). A review and analysis of the literature is also made. RESULTS: There were 10 medico-legal claims arising from vascular pathology expert representing 0.40 cases/year (1 every 3 years). Eight were from venous disease (80%) and 2 arterial disease (20%). Of these, 8 were complications during or after surgery (80%), 3 of them resulting in death (37.5%). Varicose vein surgery led to 6 claims: 2 nerve injury (sciatic nerve and saphenous nerve), one by stripping of the superficial femoral artery, and 3 fatal pulmonary embolism. No court ruling sentenced the doctor. An applicant received financial compensation. In another, the applicant was ordered to pay the court costs. This small series coincides largely with the causes of complaints identified in the literature. CONCLUSION: Compared with other specialties, vascular surgery does not have a high volume of claims. However, in vascular surgery, the treatment of varicose veins has several high risks. Specifically, the prevention of pulmonary embolism, is an aspect of the first order to avoid medico-legal claims

The superior mesenteric artery and the variations of the colic patterns. A new anatomical and radiological classification of the colic arteries.

The superior mesenteric artery (SMA) supplies irrigation to the small intestine, ascending and a variable area of the transverse colon. Although medical imaging and surgical procedures have been widely developed in the last decades, the anatomy of the SMA using advanced imaging technology remains to be elucidated. Previous studies have used small sample sizes of cadaveric or radiological samples to propose a number of classifications for the SMA. In this study, we aimed to provide a more detailed description and useful classification of the SMA and its main branches [middle colic artery (MCA), right colic artery (RCA), and ileocolic artery (ICA)]. Samples (n = 50, 28 males and 22 females) were obtained from the repository of human cadavers located at the Department of Human Anatomy and Embryology, Complutense University of Madrid. This sample was dissected by preclinical medical students and completed by two of the authors (Gamo and Jiménez). A second set of samples was obtained from a bank of computerized tomography (CT) (560 CTs, 399 males and 161 females) collected by the Radiology Department at the Clínico San Carlos Hospital, Spain. Based on the results obtained from these studies, we propose a new classification of four patterns for the SMA anatomy. Pattern I as the independent origin of the three main branches of the SMA (cadaveric 40 %; CT 73.69 %); Pattern II is subdivided in three sub-patterns based on the common trunks of origin: Pattern IIa, common trunk between RCA and MCA (cadaveric 20 %, CT 4.28 %); Pattern IIb, common trunk between RCA and ICA (cadaveric 32 %, CT 15 %); Pattern IIc, common trunk for the three main branches (cadaveric 0 %, CT 0.35 %); Pattern III, as the absence of RCA (cadaveric 8 %; CT 2.32 %) and Pattern IV, based on presence of accessory arteries (not found in any of the samples). Although the independent origin of the three colic arteries have been classically described as the most frequent, the right colic artery is responsible of major variations.

Extra-pulmonary tuberculosis: a biomarker analysis.

INTRODUCTION: Studies on biomarkers in tuberculosis are focused on pulmonary forms of this disease (PTB), and only limited information is currently available on biomarkers of extra-pulmonary tuberculosis (EPTB). METHODS: Serum samples from 24 patients with PTB, 29 patients with EPTB and 27 healthy controls were obtained, and the levels of interferon-gamma, chemokine ligand 9, mannose-binding lectin (MBL), tumor marker Ca-125 and adenosine deaminase were determined. RESULTS: The circulating levels of all tested biomarkers in the serum were significantly higher in PTB and EPTB patients than in controls. However, there were no significant differences in the levels of the biomarkers between patients with PTB and EPTB, with the exception of serum levels of MBL which were significantly higher in patients with EPTB than in patients with PTB (p = 0.01). In patients with EPTB, no significant differences were observed in biomarker levels among patients with or without concomitant PTB involvement. Based on MBL serum levels, ROC curve analysis showed an AUC of 0.85 for EPTB versus non-EPTB. The optimal cut-off value of MBL serum levels for EPTB versus non-EPTB was 1,000 µg/ml, with a sensitivity and specificity of 79.3 and 78.0 %, respectively. CONCLUSIONS: Biomarkers usually present as acute phase reactants and do not enable pulmonary forms to be differentiated from more serious or extra-pulmonary forms. MBL may be an exception.

Ca-125: a useful marker to distinguish pulmonary tuberculosis from other pulmonary infections.

INTRODUCTION: Ca-125 is secreted by different celomic epitheliums. Serum levels may be increased in malignant diseases, like ovarian cancer but also in other medical conditions, such as pulmonary and extrapulmonary tuberculosis. METHODS: From Jan-04 to Dec-06 a retrospective study analyzing Ca-125 levels in serum samples from patients with a diagnosis of pulmonary TB, was performed. These results were compared with those samples obtained from patients with non-TB pulmonary infections. RESULTS: Eighty-nine patients were included in the study, thirty-five with pulmonary TB and 54 with other respiratory infections. In patients with TB, the mean Ca-125 value was 104.9 IU/ml (SD: +/- 136.1). In the control group, mean value was 27.1 IU/ml (SD: +/-19.7). The optimal cut-off for pulmonary tuberculosis was 32.5 IU/ml (sensitivity: 68.6%, specificity: 77.8%). Pulmonary TB was the only factor associated with a Ca-125 level >32.5. In 10 patients with TB, Ca-125 levels were available >/= 2 months after starting TB therapy and a decrease during treatment was shown. CONCLUSIONS: Ca-125 values increase in patients with pulmonary TB and decline to normal values during treatment. Determination of Ca 125 may be usedin patients with a negative sputum AFB stain.

Adenosine deaminase activity in cerebrospinal fluid of HIV-infected patients: limited value for diagnosis of tuberculous meningitis.

Adenosine deaminase activity (ADA) determination in cerebrospinal fluid (CSF) is considered a specific test for the diagnosis of tuberculous meningitis. In order to study the variability of this marker in patients with different neurological disorders associated with HIV infection, and its utility for the diagnosis of tuberculous meningitis in these patients, the ADA levels in 417 CSF samples from HIV-infected patients with neurological symptoms were reviewed. HIV infection, HIV-associated neurological disorders, and progressive multifocal leukoencephalopathy were not associated with elevated ADA in CSF. Among patients with meningitis, receiver operating characteristic curve analysis gave an optimal ADA cut-off point of 8.5 IU/l for the diagnosis of tuberculous meningitis, with 57% sensitivity, 87% specificity, and an area under the curve of 0.747 (similar to that for CSF glucose concentration). False-positive results were found in patients with neurological CMV disease and cryptococcal, lymphomatous, and probable candidal meningitis. The results of this study indicate that ADA determination in CSF has limited utility for the diagnosis of tuberculous meningitis in HIV-infected patients.

Comparative study of use of Diastat versus standard wall PTFE grafts in upper arm hemodialysis access.

The objective of this study was to review our experience with using brachioaxillary Diastat vascular grafts (Diastat) compared to standard wall brachioaxillary PTFE grafts (sPTFE) in two similar groups of hemodialysis patients. We conducted a retrospective study comparing complications and graft survival in two similar groups (in terms of age, diabetes mellitus, surgical technique, and previous vascular access) of hemodialysis patients during the period 1994-1997 who had received Diastat (n = 40) or (sPTFE) (n = 40) grafts. We found that the Diastat graft for upper arm hemodialysis access has lower patency and higher complication rates than sPTFE grafts.

The value of air plethysmography in predicting clinical outcome after surgical treatment of chronic venous insufficiency.

PURPOSE: The role of air plethysmography (APG) as a predictor of clinical outcome after surgery in venous disease is yet to be defined. The purpose of this study was to investigate the value of APG in predicting clinical outcome after venous surgery for chronic venous insufficiency (CVI). METHODS: Seventy-three extremities in 71 patients with Class 3 through 6 CVI were assessed preoperatively with CEAP (c linical, e tiologic, a natomic, p athophysiologic) criteria, standing reflux duplex ultrasound scan, and APG with measurements of preoperative venous filling index (VFI), venous volumes, ejection fraction, and residual volume fraction. After surgical treatment of the affected limbs, repeat APG studies were obtained within 6 weeks. Established venous reporting standards were used for follow-up to calculate clinical symptom scores (CSSs) in each patient. RESULTS: Superficial venous reflux occurred alone in 24 limbs or in conjunction with perforator incompetence in 26 limbs. Deep and superficial reflux, with or without perforator incompetence, was found in 16 limbs, and seven limbs had isolated deep insufficiency. Follow-up was available in 60 of 71 patients (mean period, 44.3 months). Postoperative APG demonstrated significant hemodynamic changes after surgery as measured with VFI, venous volumes, ejection fraction, and residual volume fraction. Mean CSSs decreased from 7.35 +/- 0.56 preoperatively to 1.79 +/- 0.32 at late follow-up after surgery (P <.001). With the use of logistic regression, the parameter correlating most closely with clinical outcome was the VFI. A normal postoperative VFI (

Trombosis de senos venosos cerebrales y colitis ulcerosa / Cerebral venous sinus thrombosis and ulcerative colitis

La EEI se acompaña de múltiples manifestaciones extraintestinales, entre ellas un estado de hipercoagulabilidad que puede dar lugar a fenómenos tromboembólicos. Entre estos últimos están las trombosis venosas cerebrales (TVC) que son raras y pueden dar lugar a un cuadro poco llamativo, pasando desapercibidas. Describimos el caso de un paciente diagnosticado previamente de colitis ulcerosa que presentó TVC como primera manifestación de un síndrome de hipercoagulabilidad. Se revisa la literatura y se comentan los mecanismos patogénicos (AU)

ADA1/ADAp ratio in pleural tuberculosis: an excellent diagnostic parameter in pleural fluid.

We analysed the efficacy of pleural adenosine deaminase (ADAp) and the ADA1/ADAp ratio in the diagnosis of pleural tuberculosis in 103 pleural effusions, 27 of which were tuberculosis (TB) and 76 other diagnoses (non-TB). Smears, cultures and pleural biopsies were carried out in all cases, and were used for final diagnosis. The diagnostic yield of the parameters under study were as follows: smears/cultures of mycobacteria in fluid 11.1%/33.3%; biopsy 33.3%/51.8% and tuberculosis granulomas 85.1%. The levels of ADAp and ADA1/ADAp ratio in TB and non-TB groups showed very significant differences (P < 0.00001); in the TB group: ADAp 54.7 +/- 23.5 IU and ADA1/ADAp 0.27 +/- 0.08; in the non-TB group: ADAp 18.3 +/- 43.2 IU and ADA1/ADAp 0.64 +/- 0.14. The assay established ADA levels in pleural fluid > or = 40 IU and an ADA1/ADAp ratio < or = 0.42 as cut-off levels to identify individuals in the TB group, with a sensitivity of 88.8%/100%, a specificity of 92%/98.6%, a positive predictive value (PPV) of 80%/96.4%, a negative predictive value (NPV) of 95.8%/100% and an accuracy of 91.2%/99.02%. The ADAp levels in 27 patients with TB, showed close correlation with the number of monocyte macrophages (P = 0.001), but not with the number of lymphocytes (P = n.s.). The ADA1/ADAp ratio overcomes the limitations of ADAp (false positives and negatives), and is the most useful parameter for diagnosis on account of a high diagnostic yield, low cost and speed of the assay for identifying a pleural tuberculosis diagnosis, when compared with traditional methods.

[Evaluation of biochemical markers of myocardial lesion after radiofrequency ablation. Value of troponin I]. / Evaluación de marcadores de lesión miocárdica tras la ablación con radiofrecuencia. Utilidad de la troponina I.

INTRODUCTION AND OBJECTIVES: Radiofrequency catheter ablation is the curative treatment of choice for many cardiac arrhythmias. After radiofrequency ablation there is always a localized endomyocardial necrosis, which is necessary to eliminate the arrhythmia. The volume of the necrosis may be evaluated by the rise of several biochemical markers, classically CK and CK-MB. However, the sensitivity and specificity of these markers are not optimal and are probably less than ideal for this purpose. Cardiac Troponin I (cTnI) is a newly available biochemical marker available, with a high cardiac specificity. We designed this study in order to determine the value of serum levels of several cardiac markers in patients who underwent radiofrequency catheter ablation and to establish the utility of cTnI. METHODS: We analyzed the data from 51 patients who underwent radiofrequency ablation and from 16 control patients. In respect to the ablation target, we included in the study 14 left accessory pathways, 7 right accessory pathways, 12 atrioventricular nodal reentry tachycardia, 5 ventricular tachycardia and 13 atrial flutter or fibrillation. The levels of CK, CK-MB, cTnI, and myoglobin were compared with clinical findings, ST-T wave abnormalities and the presence of arrhythmias after ablation. To evaluate the diagnostic capability for each biochemical marker we used the ROC curves. RESULTS: A pathological value of cTnI was found in 47 out of 51 (92%) patients in the ablation group. CK-MB had a lower sensitivity (63%). The sensitivity for the other biochemical markers ranged from 30% for CK to 67% for Myoglobin. The area under the ROC curve for cTnI was 0.9375, significantly superior to the other biochemical markers (0.86, 0.76, 0.75 for MB, Myoglobin, CK respectively) (p < 0.05). The lowest cTnI released was found in patients after nodal reentry tachycardia ablation and the highest after atrial flutter ablation. cTnI increased above normal values in 4 patients in the control group (patients who underwent an electrophysiological study without catheter ablation). We found a moderate level of correlation between the number of radiofrequency pulses and cardiac cTnI release (r = 0.69; p < 0.0001). The correlation was different in each target, ranging between r = 0.25 (p = NS, 0.43) for atrial flutter and fibrillation to r = 0.99 (p < 0.0001) for ventricular tachycardia. CONCLUSIONS: cTnI had the greatest sensitivity (92%) for detecting minor myocardial damage. Thus, we can conclude that the serum level of cTnI detects the minor myocardial damage produced by radiofrequency ablation.

Lactate dehydrogenase isoenzymes in patients with essential thrombocythemia.

Various abnormalities have been described in platelets of patients with Essential Thrombocythemia (ET), including alteration in the glycolytic pathway and increased lactate production. Lactate dehydrogenase (LDH) isoenzymes were studied in 15 of these patients. Relative activity of LDH-5 isoenzyme was higher comparing with normal platelets (p < 0.05), while LDH-3 activity was diminished (p < 0.05). LDH-1, LDH-2 and LDH-4 isoenzymes were unchanged. We also found an altered profile of LDH isoenzymes in serum. These findings can contribute to improve the knowledge of platelet defects in ET and be useful in the diagnosis of these patients.

[Salmonella typhimurium as the causal agent of pulmonary cavitations]. / Salmonella typhimurium como agente productor de cavidades pulmonares.

BACKGROUND: Relation between patients with immunosuppression (malignancy, renal transplant) and bacteremia by Salmonella non-typhi, specially by Salmonella typhimurium, is known. This relation has been published for patients who suffer from AIDS, and so Salmonella bacteremia could even begin the clinical disease. But even though the relation between the infection by Salmonella and AIDS is well known, and the pulmonary involvement in them has been told, this etiology as a producing agent of lung cavitation has not much documentation. METHODS: We examined three patients (two women and one man) suffering from fever of one week of duration, cough, expectoration and thoracic pain in two of them. The third patient had fever and cachexia without clinical symptoms. The man and the two women had a blood count with neutrophilia and leucocytosis in two cases and leucopenia in the other one. All of them suffered a very important depression of cell immunity (CD4 of 140, 70 and 4, respectively) and positive blood cultures for Salmonella typhimurium. RESULTS: Chest X-Ray showed, in all the cases, pulmonary cavities. CONCLUSIONS: Salmonella typhimurium must be included among the agents that can produce pulmonary cavities like Staphylococcus aureus, mycobacteria, fungus and other gram-negative bacilli.

[Sepsis caused by Mycobacterium tuberculosis in patients with AIDS]. / Sepsis por Mycobacterium tuberculosis en pacientes con SIDA.

BACKGROUND: Techniques for detecting mycobacteria in blood can be a good alternative for diagnosing tuberculosis in acquired-immunodeficiency syndrome patients (AIDS). PATIENTS AND METHODS: Eleven patients with AIDS and pulmonary tuberculosis, and four controls with AIDS and without tuberculosis were studied. The diagnosis of mycobacteremia was made by the identification of the microorganisms in blood. The method used was a lysis-centrifugation with subsequent stain or culture identification in different media (agar Löwenstein-Jensen, M7H9, M7H11, brain-heart infusion and Sauton broth). RESULTS: In one case, direct staining of sample was positive. The culture results were positive in all 11 patients with tuberculosis and in none of the controls. M7H11 was the media that allows the fastest detection. CONCLUSIONS: This technique can be a good alternative method for tuberculosis diagnosis in AIDS patients. Is easy to perform, relatively fast an with diagnostic performance. It also could be of interest in extra-pulmonary tuberculosis.